诱发电位监测对颅内动脉瘤手术中脑缺血性改变及其耐受程度的研究
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摘要
目的探讨颅内动脉瘤手术中诱发电位信号变化与脑缺血及其耐受程度之间的关系。方法对47例颅内动脉瘤夹闭术患者术中进行体感诱发电位(SEP)和/或运动诱发电位(MEP)监测,记录术中载瘤动脉临时阻断、穿支血管误夹或脑血管痉挛后诱发电位达到预警标准的时间及其达到预警标准后持续至解除引起诱发电位改变的相关操作的时间、解除相关操作后诱发电位恢复的时间,根据术后患者有无新的运动功能受损(肌力的下降)和/或术后CT检查相应部位有无出现新鲜梗塞灶判断是否造成新的脑缺血性损伤,并将两者进行相关性分析研究。结果术中35例成功进行SEP和MEP监测,10例单独行SEP监测,2例单独行MEP监测,术后共10例出现新鲜梗塞灶和/或新的运动功能受损。24小时内出现缺血性改变者7例,其中CT出现缺血性改变者6例,运动功能受损者3例,24小时后出现缺血性改变者3例,其中CT出现缺血性改变者2例,运动功能受损者1例。术中出现明显SEP改变有共13例,其中5例术后出现缺血性改变,载瘤动脉阻断引起的缺血耐受比(临时阻断过程中体感诱发电位达到预警标准后持续至临时阻断解除的时间/临时阻断至体感诱发电位达到预警标准的时间×100%)在80%以上者(4例)全部出现术后缺血性改变,而在50%以下的患者(8例)均未出现缺血性改变,另外1例由穿支血管夹闭所致。在术中出现MEP改变8例中,术后出现缺血性改变4例(其中包括术中SEP正常而术后出现缺血性改变的3例患者)。结论术中诱发电位的改变程度与术后脑缺血具有较好的相关性,由于个体的差异性,并不存在安全的阻断时限,但在体感诱发电位下监测的缺血耐受比具有较为客观的预测价值,将缺血耐受比保持在50%以下可以有效的避免术后脑缺血的发生,如果缺血耐受比超过80%将不可避免术后出现脑缺血,同时在监测穿支血管所致的缺血性改变时,MEP监测具有更良好的优势,联合SEP和MEP在颅内动脉瘤手术过程中是非常重要的。
Objective To evaluate the relationship between evoked potential signal changes and cerebral ischemia and the tolerance in the intracranial aneurysm surgery. Methods 47 patients with somatosensory evoked potential (SEP) and / or motor evoked potentials (MEP) monitoring in intracranial aneurysm surgery, recording the appearing time ,duration and recovery time of temporary occlusion of artery, wrong clipping of perforating vessels or cerebral vasospasm when the evoked potentials change, and using the appearance of new postoperative motor function impairment (decreased myodynamia) and / or postoperative CT examination corresponding to the emergence of fresh infarct area to determine whether the result of new cerebral ischemic injury, and analysing the correlation between the evoked potentials changes and new cerebral ischemic injury .Results 35 cases with SEP and MEP monitoring, 10 cases with single SEP monitoring, two cases with single MEP monitoring, a total of 10 cases with fresh infarct and / or new motor function impairment after sugery, 3 patients died. 7 cases suffer from ischemic changes within 24 hours (6 cases with ischemic changes in CT, 3 cases with impaired motor function), 3 cases suffer from ischemic changes after 24 hours( of which CT ischemic changes occurred in 2 cases with ischemic changes in CT, 1 case with motor function impairment). The intraoperative SEP changed in 13 cases(5 cases suffered from ischemic changes), and among them 4 cases suffered from postoperative ischemia which the Ischemic Tolerance Ratio was more than 80%,8 cases did not suffer from postoperative ischemia which the Ischemic Tolerance Ratio was less than 50%, another one case which suffered from postoperative ischemia was caused by the clipping of perforating vessel. The intraoperative MEP changed in 8 cases, of which 4 cases suffering from postoperative ischemia (including 3 cases which the intraoperative SEP was normal). Conclusion Intraoperative significant changes in evoked potentials was related to postoperative ischemia, particularly the Ischemic Tolerance Ratio was a objective indicator to predict postoperative ischemia, but in monitoring the ischemia of perforating vessel, MEP monitoring was better than SEP, so combining SEP with MEP in the process of intracranial aneurysm surgery was very important.
Objective To evaluate the relationship between evoked potential signal changes and cerebral ischemia and the tolerance in the intracranial aneurysm surgery. Methods 47 patients with somatosensory evoked potential (SEP) and / or motor evoked potentials (MEP) monitoring in intracranial aneurysm surgery, recording the appearing time ,duration and recovery time of temporary occlusion of artery, wrong clipping of perforating vessels or cerebral vasospasm when the evoked potentials change, and using the appearance of new postoperative motor function impairment (decreased myodynamia) and / or postoperative CT examination corresponding to the emergence of fresh infarct area to determine whether the result of new cerebral ischemic injury, and analysing the correlation between the evoked potentials changes and new cerebral ischemic injury .Results 35 cases with SEP and MEP monitoring, 10 cases with single SEP monitoring, two cases with single MEP monitoring, a total of 10 cases with fresh infarct and / or new motor function impairment after sugery, 3 patients died. 7 cases suffer from ischemic changes within 24 hours (6 cases with ischemic changes in CT, 3 cases with impaired motor function), 3 cases suffer from ischemic changes after 24 hours( of which CT ischemic changes occurred in 2 cases with ischemic changes in CT, 1 case with motor function impairment). The intraoperative SEP changed in 13 cases(5 cases suffered from ischemic changes), and among them 4 cases suffered from postoperative ischemia which the Ischemic Tolerance Ratio was more than 80%,8 cases did not suffer from postoperative ischemia which the Ischemic Tolerance Ratio was less than 50%, another one case which suffered from postoperative ischemia was caused by the clipping of perforating vessel. The intraoperative MEP changed in 8 cases, of which 4 cases suffering from postoperative ischemia (including 3 cases which the intraoperative SEP was normal). Conclusion Intraoperative significant changes in evoked potentials was related to postoperative ischemia, particularly the Ischemic Tolerance Ratio was a objective indicator to predict postoperative ischemia, but in monitoring the ischemia of perforating vessel, MEP monitoring was better than SEP, so combining SEP with MEP in the process of intracranial aneurysm surgery was very important.
引文
[1]Mario Cabraja,M.D.,Florian StockhaMMer,M.D.,Sven ularSki,M.D. Neurophysiological intraoperative monitoring in neurosurgery:aid or handicap? Neurosurg Focus,2009,27(4): 1-7.
[2]Heros RC(1985) .Middle cerebral artery aneurysms.In:Wilkins RH, Rengachary SS(eds) Neurosurgery,vol 2.McGraw-Hill Inc,New York, pp 1376–1383.
[3]Lavine SD,Masri LS,Levy ML,Giannotta SL. Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery:time limitation and advantage of brain protection. J Neurosurg,1997,87: 817–824.
[4]SamsonD,BatjerHH,BowmanG,et.A clinical studyfohteparma eters na d efects fo tempo rary arterila occlusion in htemna agement fo intracranil aneurysms[J].Neuorsurgeyr,1994,34:22-29.
[5]G.Penchet1,P.Arne,E.Cuny,P.Monteil, H.Loiseau1,and J.-P.Castel1. Use of intra-operative monitoring of somatosensory evoked potentials to prevent ischaemic stroke after surgical exclusion of middle cerebral artery aneurysms[J].Acta Neurochir,2007,149:357-364.
[6]Tatsuya Sasaki,M.D.,Namio Kodama,M.D.,PH.D.,Masato Matsumoto,M.D. , Kyouichi S- uzuki,M.D.,Yutaka Konno,M.D.,PH.D.,Jun Sakuma,M.D., PH. D.,Yuji Endo,M.D.,AND Masahiro Oinuma,M.D. Blood flow disturbance in perforating arteries attributable to aneurysm surgery[J]. J Neurosurg 107:60–67,2007.
[7]Fukasawa H:Hemodynamic studies of cerebral arteries by means of mathematical analysis of arterial casts[J].Tohoku J Exper Med 99:255–268,1969.
[8]KANG De-zhi,WU Zan-yi,LAN Qing,YU Liang-hong,LIN Zhang-ya,WANG Chen-yang and LIN Yuan-xiang.Combined monitoring of evoked potentials during microsurgery for lesions adjacent to the brainstem andintracranial aneurysms[J]. Chinese Medical Journal 2007;120(18): 1567- 1573.
[9]Quinones Hinojosa A;Alam M;Lyon R;Yingling CD;Lawton MT. Transcranial motor evoked potentials during basilar artery aneurysm surgery: technique application for 30 consecutive patients. J Neurosurg.2004;54:916-924.
[1] Lang EW,Beutler AS,Chestnut RM,Patel PM,Kennelly NA,Kalkman CJ,Drummond JC,Garfin SR.Myogenic motor-evoked potential monitoring using partial neuromuscular blochkade in surgery of the spine[J].Spine 1996;21:1676-1686.
[2]Cohen D,Cuffin BN.Developing a more focal magnetic stimulator.PartⅠ:Some basic principles[J]. Clin Neurophysiol 1991;8:102-11.
[3] Neil R.Holland.Subcortical Strokes From Intracranial Aneurysm Surgery:Implications for Intraoperative Neuromonitoring [J].Clinical Neurophysiolo- gy,1998,15:439-446.
[4]Tatsuya Sasaki,M.D.,Namio Kodama,M.D.,PH.D.,Masato Matsumoto,M.D., Kyouichi Suzuki,M.D.,Yutaka Konno,M.D.,PH.D.,Jun Sakuma,M.D.,PH.D.,Yuji endo,M.D.,AND Masahiro Oinuma,M.D. Blood flow disturbance in perforating arteries attributable to aneurysm surgery[J]. Neurosurgy 2007,107:60–67.
[5]Banoubm,Tetzlaffje,Schuberta.Pharmacologic and physiologic influence affecting sensory evoked potentials : implications for perioperative monitoring[J].Anesthesiology,2003,99(3):716-737.
[6] Jaime R.Lopez.MD.The use of evoked potentials in intraoperative neurophysiologic monitoring [J].Phys Med Rehabil Clin N Am. 2004,15:63-84 .
[7]Wakasugim,Hirotak,Rothsh,eta1.The effects Of general anaesthetics on excitatory and inhibitory synaptic Transmission in area CA1 of the rat hippocampus in vitro[J]. Anesth Analg,1999,88(3):676-680.
[8]Boisseaun,Madany m,Staccinip,et a1.Comparison of the effects of sevolfurane and propofol on cortical somatosensoy evoked potentials[J].Br J Anaesh,2002,88(6):785-789.
[9]RezaG.Anesthesia and Neuromonitoring:E1ectroencephalography and Evoked Potentials[M].//RezaG.Neurophysiology Lecture.Syracuse,NY,2OO8:11—12.
[10]YamamotoY,Kawaguchi M,Hayashi H,et a1.The effects of the neuromuscular blockade leve1s on amplitudes of posttetanic motor-evoked potentia1s and movement in response to transcranial stimulation in patients receiving propofol and fentanyl[J].Anesth Analg,2008,l06:930—934.
[11]Banoub M,Tetlaff JE,Schubert A.Pharmacologic and physiologic influences affecting sensory evoked potentials.ANESTHESIOLGY.2003;99:716-737.
[12]Evoked Potential in Clinical Medicine 3rd Edition 1997 Chiappa KH,Lippincott-Raven.
[13]Banoub M,Tetlaff JE,Schubert A.Pharmacologic and physiologic influences affecting sensory evoked potentials.ANESTHESIOLGY.2003;99:716-737.
[14]A.Szelenyi,D.Langer,J.Beck ,A.Raabe,E.S.Flamm,V.Seifert,V.Deletis. Trans- cranial and direct cortical stimulation for motor evoked potential monitoring in intracerebral aneurysm surgery. Clinical Neurophysiology.2007,37,391—398.
[2]Heros RC(1985) .Middle cerebral artery aneurysms.In:Wilkins RH, Rengachary SS(eds) Neurosurgery,vol 2.McGraw-Hill Inc,New York, pp 1376–1383.
[3]Lavine SD,Masri LS,Levy ML,Giannotta SL. Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery:time limitation and advantage of brain protection. J Neurosurg,1997,87: 817–824.
[4]SamsonD,BatjerHH,BowmanG,et.A clinical studyfohteparma eters na d efects fo tempo rary arterila occlusion in htemna agement fo intracranil aneurysms[J].Neuorsurgeyr,1994,34:22-29.
[5]G.Penchet1,P.Arne,E.Cuny,P.Monteil, H.Loiseau1,and J.-P.Castel1. Use of intra-operative monitoring of somatosensory evoked potentials to prevent ischaemic stroke after surgical exclusion of middle cerebral artery aneurysms[J].Acta Neurochir,2007,149:357-364.
[6]Tatsuya Sasaki,M.D.,Namio Kodama,M.D.,PH.D.,Masato Matsumoto,M.D. , Kyouichi S- uzuki,M.D.,Yutaka Konno,M.D.,PH.D.,Jun Sakuma,M.D., PH. D.,Yuji Endo,M.D.,AND Masahiro Oinuma,M.D. Blood flow disturbance in perforating arteries attributable to aneurysm surgery[J]. J Neurosurg 107:60–67,2007.
[7]Fukasawa H:Hemodynamic studies of cerebral arteries by means of mathematical analysis of arterial casts[J].Tohoku J Exper Med 99:255–268,1969.
[8]KANG De-zhi,WU Zan-yi,LAN Qing,YU Liang-hong,LIN Zhang-ya,WANG Chen-yang and LIN Yuan-xiang.Combined monitoring of evoked potentials during microsurgery for lesions adjacent to the brainstem andintracranial aneurysms[J]. Chinese Medical Journal 2007;120(18): 1567- 1573.
[9]Quinones Hinojosa A;Alam M;Lyon R;Yingling CD;Lawton MT. Transcranial motor evoked potentials during basilar artery aneurysm surgery: technique application for 30 consecutive patients. J Neurosurg.2004;54:916-924.
[1] Lang EW,Beutler AS,Chestnut RM,Patel PM,Kennelly NA,Kalkman CJ,Drummond JC,Garfin SR.Myogenic motor-evoked potential monitoring using partial neuromuscular blochkade in surgery of the spine[J].Spine 1996;21:1676-1686.
[2]Cohen D,Cuffin BN.Developing a more focal magnetic stimulator.PartⅠ:Some basic principles[J]. Clin Neurophysiol 1991;8:102-11.
[3] Neil R.Holland.Subcortical Strokes From Intracranial Aneurysm Surgery:Implications for Intraoperative Neuromonitoring [J].Clinical Neurophysiolo- gy,1998,15:439-446.
[4]Tatsuya Sasaki,M.D.,Namio Kodama,M.D.,PH.D.,Masato Matsumoto,M.D., Kyouichi Suzuki,M.D.,Yutaka Konno,M.D.,PH.D.,Jun Sakuma,M.D.,PH.D.,Yuji endo,M.D.,AND Masahiro Oinuma,M.D. Blood flow disturbance in perforating arteries attributable to aneurysm surgery[J]. Neurosurgy 2007,107:60–67.
[5]Banoubm,Tetzlaffje,Schuberta.Pharmacologic and physiologic influence affecting sensory evoked potentials : implications for perioperative monitoring[J].Anesthesiology,2003,99(3):716-737.
[6] Jaime R.Lopez.MD.The use of evoked potentials in intraoperative neurophysiologic monitoring [J].Phys Med Rehabil Clin N Am. 2004,15:63-84 .
[7]Wakasugim,Hirotak,Rothsh,eta1.The effects Of general anaesthetics on excitatory and inhibitory synaptic Transmission in area CA1 of the rat hippocampus in vitro[J]. Anesth Analg,1999,88(3):676-680.
[8]Boisseaun,Madany m,Staccinip,et a1.Comparison of the effects of sevolfurane and propofol on cortical somatosensoy evoked potentials[J].Br J Anaesh,2002,88(6):785-789.
[9]RezaG.Anesthesia and Neuromonitoring:E1ectroencephalography and Evoked Potentials[M].//RezaG.Neurophysiology Lecture.Syracuse,NY,2OO8:11—12.
[10]YamamotoY,Kawaguchi M,Hayashi H,et a1.The effects of the neuromuscular blockade leve1s on amplitudes of posttetanic motor-evoked potentia1s and movement in response to transcranial stimulation in patients receiving propofol and fentanyl[J].Anesth Analg,2008,l06:930—934.
[11]Banoub M,Tetlaff JE,Schubert A.Pharmacologic and physiologic influences affecting sensory evoked potentials.ANESTHESIOLGY.2003;99:716-737.
[12]Evoked Potential in Clinical Medicine 3rd Edition 1997 Chiappa KH,Lippincott-Raven.
[13]Banoub M,Tetlaff JE,Schubert A.Pharmacologic and physiologic influences affecting sensory evoked potentials.ANESTHESIOLGY.2003;99:716-737.
[14]A.Szelenyi,D.Langer,J.Beck ,A.Raabe,E.S.Flamm,V.Seifert,V.Deletis. Trans- cranial and direct cortical stimulation for motor evoked potential monitoring in intracerebral aneurysm surgery. Clinical Neurophysiology.2007,37,391—398.